CPT code 29806 , 29822 - 29823, 29824, 29826, 29827 -shoulder Arthroscopy

Procedure code and description

29806   ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY

29807   ARTHROSCOPY SHOULDER SURGICAL REPAIR SLAP LESION

29819   ARTHROSCOPY SHOULDER SURGICAL REMOVAL LOOSE/FB

29820   ARTHROSCOPY SHOULDER SURG SYNOVECTOMY PARTIAL

29821   ARTHROSCOPY SHOULDER SURG SYNOVECTOMY COMPLETE

29822   ARTHROSCOPY SHOULDER SURG DEBRIDEMENT LIMITED

29823   ARTHROSCOPY SHOULDER SURG DEBRIDEMENT EXTENSIVE average fee payment - $680 - $690

29824   ARTHROSCOPY SHOULDER DISTAL CLAVICULECTOMY

29825   ARTHROSCOPY SHOULDER AHESIOLYSIS W/WO MANIPJ

29826   ARTHROSCOPY SHOULDER W/CORACOACRM LIGMNT RELEASE

29827   ARTHROSCOPY SHOULDER ROTATOR CUFF REPAIR average fee amount - $1000 - $1100

29828   ARTHROSCOPY SHOULDER BICEPS TENODESIS


29826 - Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromialligament (ie, arch) release, when performed (List separately in addition to code for primary procedure)    average fee amount - $150 - $200


Billing and Coding Guidelines


The transition to the new CMS ASC payment system, which pays centers at a percentage of HOPD rates, has increased the reimbursement rates of most orthopedic procedures, says Jay Rom, president of Blue Chip Surgical Center Partners. The system, which went into effect Jan. 1, 2008, and was designed to be phased in over a four-year period, continues to benefit orthopedic service lines as the percent of the payment formula determined by the new system is phased into the overall ASC reimbursement rate.

The 2010 Medicare unadjusted base rates for a few of the more popular ASC orthopedic procedures are as follows:

• Arthroscopy, shoulder (CPT 29806) —$1,588.70


Bundled as a component of these arthroscopic procedures:
– 29827 RC repair
– 29828 Biceps tenodesis
– 29807 SLAP repair



Co-surgery diagnosis

If there is a co-surgery, the diagnosis has to match for both OP notes.

Osteoarthritis

When coding for Osteoarthritis we will need the following to be documented within the OP note in order to code and process for billing within a timely manner. I know this is a repeat from last month, but we are starting to receive denials for the use of a more specific diagnosis code.

• Nature of Osteoarthritis (Primary, Secondary, post-traumatic)

• Laterality (Left, Right, Bilateral)

• Anatomical Location (Hip, Knee, CMC, etc.)

What to code when only an Acromioplasty is performed alone(29826) 29826 is defined as an Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure).

• This code can only be reported with other scope procedures

• It is not a stand alone code

• If this is the only procedure performed, you should report 29822/29823 per Procedure and AAOS

• What to do if performed with an open procedure… o Procedure 29826 should not be reported with any procedure other than those identified as appropriate parent codes. It is not an add-on code to Procedure 23410 or 23412, and an unlisted code cannot be reported to reflect this work. Instead, you should report 29822 or 29823 as appropriate.


Column 1 Code / Column 2 Code - 29827/29820

* Procedure Code 29827 – Arthroscopy, shoulder, surgical; with rotator cuff repair

* Procedure Code 29820 – Arthroscopy, shoulder, surgical; synovectomy, partial

Procedure code 29820 should not be reported and modifier 59 should not be used if both procedures are performed on the same shoulder during the same operative session because the shoulder joint is a single anatomic structure. If the procedures are performed on different shoulders, modifiers RT and LT should be used, not modifier 59.

Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ

Orthopedics. Medicare edits bundle Procedure  29823 (Arthroscopy, shoulder extensive debridement) into Procedure  29824 (Arthroscopy, shoulder, surgical; distal claviculectomy) at this time but allows for a modifier if the debridement is performed separate and distinct from the distal claviculectomy.



 Medicare professional fees for orthopedic procedures are, on average, more than 40 percent less than the average commercial payments. Medicare pays physicians significantly less than commercial payors for performing orthopedic procedures, but the differences between the two payors vary by procedure. For example, the Medicare allowable for a shoulder arthroscopy with lysis and resection of adhesions (CPT 29825) is $593 while the average commercial payment for the procedure in $1,350 — a payment of more than double the Medicare allowable. The Medicare allowable for shoulder arthroscopy; capsulorrhaphy (CPT 29806) is $1,071, and the average commercial payment is $1,285 — only 16 percent more than the Medicare allowable.
Rotator cuff repair and reconstruction 

Use Procedure code series 23410 to 23412 to report mini open rotator cuff tear repairs, with code selection determined by acute versus chronic conditions. While Procedure provides a parenthetical statement under  29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair) directing the Procedure user to report 23412 for mini open rotator cuff repair, you still need to determine the final code selection based on the acute versus chronic condition. Recall that Procedure code verbiage in 23410 to 23420 is specific to an acute versus chronic condition.

Mini open rotator cuff tear repairs typically don’t involve entry into the shoulder joint while the tear can still be visualized and repaired. When a surgeon performs an arthroscopic rotator cuff repair, report  Procedure 29827 regardless of whether the condition is acute versus chronic.

The operative report should specify an acute versus chronic condition. The technique (open versus arthroscopic) will need to be apparent to include a detailed description of a repair versus reconstruction of the specific tendon(s) or cuff.

CCI Edits and Bundling CMS Guidelines 

•Effective Apr. 1, 2012 the edit bundling Procedure code 29822 into 29826 will be removed

•After Apr. 1, 2012, the provider may resubmit the claim if the local A/B MAC permits, or appeal previously denied claims involving the NCCI edit code pair (Opportunity to increase revenue on previously denied claims when the ASC remains updated to changes)

Column 1 Code / Column 2 Code - 29827/29820

>CPT Code 29827 – Arthroscopy, shoulder, surgical; with rotator cuff repair

>CPT Code 29820 – Arthroscopy, shoulder, surgical; synovectomy, partial

CPT code 29820 should not be reported and modifier 59 should not be used if both procedures are performed on the same shoulder during the same operative session because  the shoulder joint is a single anatomic structure. If the procedures are performed on different shoulders, modifiers RT and LT should be used, not modifier 59.

Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs, or different anatomic regions, or  in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ.



Rotator Cuff Codes

Procedure Code          Procedure             MCR 


29827 Arthroscopic surgical  shoulder; repair of rotator cuff    $1,342.79


Background:

The Medicare beneficiary underwent a surgical procedure at the Appellant’s ASC facility on March 25, 2011. Medical documentation in the record consists of an Operative Report dated March 25, 2011 that the surgeon, Thomas B. Viehe, M.D., authored. Exh 1 at P 099. In addition to identifying the preoperative and postoperative diagnoses, the Operative Report includes a description of the procedure. The section for “Operation(s) Performed” includes the following entries:

1. Right shoulder arthroscopic rotator cuff repair.

2. Right shoulder arthroscopic subacromial decompression with partial acromioplasty.

3. Right shoulder arthroscopic distal clavicle resection.

4. Right shoulder arthroscopic glenohumeral joint debridement, extensive.

Id. The report also included a detailed description of the procedure. Id.
 The ASC facility billed Medicare for Procedure codes 29823 (arthroscopy, shoulder, surgical;  debridement, extensive), 29824 (arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (mumford procedure)), 29826 (arthroscopy, shoulder, surgical, decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed, 29827 (arthroscopy, shoulder, surgical; with rotator cuff repair) and 29999 (unlisted procedure, arthroscopy).

Wisconsin Physicians Services (WPS), the Medicare Part B contractor in the Appellant’s jurisdiction, reimbursed the facility for 29823, 29824, 29826 and 29827 but denied payment for 29999. Id. at P 097. According to the Remittance Advice, 29999 denied on the basis that “this procedure code/bill type is inconsistent with the place of service.”  

The ASC’s basis for appeal was essentially the same at all levels: “code 29999 is used for arthroscopic biceps tenotomy, as there is no more specific code.In its re determination notice, WPS explained:


Surgeons bill separately for physician’s services. The physician’s bill is not at issue in this case. We note, however, that review of the Health Insurance Master Record (HIMR) shows the physician billed and was paid for 29823, 29824, 29826 and 29827. We were unable to locate any record indicating the physician either billed for or was paid for Procedure code 29999.3 Nothing in the Operative Report indicates that the physician performed a  separate procedure, considered the biceps tenotomy to be a separately identifiable procedure, or intended to bill Medicare for a separate procedure.

As discussed above, both the Part B contractor and the QIC allowed payment for 29823, 29824, 29826 and 29827 but denied payment for 29999 because 29999 is non covered when provided in an ASC facility. Thus, the WPS and QIC decisions appear to be wholly consistent with the surgeon’s report and claim information, which indicate that four separate and distinct procedures—not five—were performed and billed.

As part of its agreement with CMS, an ASC agrees to charge the beneficiary only the applicable deductible and coinsurance amounts for facility services for which the beneficiary is entitled to have payment made on his or her behalf. 42 CFR § 416.30. The Appellant billed, and was paid, for 29823, 29824, 29826 and 29827. This constitutes payment in full for services performed. Pursuant to 42 CFR § 416.30, the appellant may not charge the beneficiary for more than the applicable deductible and coinsurance for 29823, 29824, 29826 and 29827.


Conclusion:

The beneficiary underwent arthroscopic shoulder surgery at the Appellant’s ASC facility.

The Appellant billed Medicare, and was paid, for Procedure codes 29823, 29824, 29826 and 29827. The Appellant also billed Medicare for unlisted procedure code 29999 because there was no specific billing code assigned to arthroscopic biceps tenotomy. Exh 6 at P 032.

CMS regulations are binding on Office of Medicare Hearings and Appeals ALJs. 42 CFR § 405.1063(a). Pursuant to 42 CFR § 416.166(b), Medicare only pays ASCs for services that appear on a list of approved services published in the Federal Register and for which separate payment is made under OPPS. Procedure code 29999 is not an approved service when furnished in an ASC. 75 FR 72279-72331, November 24, 2010,

Addendum AA. Under 42 CFR § 416.166(c)(7), services that can only be reported using an unlisted surgical Procedure code are excluded from coverage in an ASC. CMS has also expressly excluded Procedure code 29999 from coverage when furnished in an ASC.




Rational Edit Guidelines


Anthem Central Region bundles 29807 as incidental with 29806, bundles 29807-50 as incidental to 29806-50, bundles 29807-LT as incidental to 29806-LT and bundles 29807-RT as incidental with 29806-RT. Based on NCCI, code 29807 is listed as a component code to code 29806. Therefore, if 29807 is submitted with 29806—only 29806 reimburses, if 29807-50 is submitted with 29806-50— only 29806-50 reimburses, if 29807-LT is submitted with 29806-LT—only 29806-LT reimburses Anthem Central Region does not bundle 29807-LT with 29806-RT. If procedure 29807 is performed on one shoulder and 29806 is performed on the opposite shoulder append the appropriate side modifier (LT or RT) to 29807-LT and the opposite side modifier to the other procedure 29806-RT. Therefore, if 29807-LT is submitted with 29806-RT—both procedures
reimburse separately.

Anthem Central Region does not bundle 29807-59 with 29806. If arthroscopic SLAP lesion repair is a type 2 or 4 append modifier 59 to 29807-59 to allow both 29807-59 and 29806 to reimburse separately. If 29807 is a SLAP type 1 or 3 lesion do not append modifier 59 to 29807 and 29807 does not reimburse separately with 29806. If 29807 is performed on one shoulder and 29806 is performed on the opposite shoulder append modifier 59 to one of these procedures and both procedures reimburse separately.

If on a complaint/appeal it is document that 29807 was performed on one shoulder and 29806 was  performed on the opposite shoulder both procedures reimburse separately If on a complaint/appeal it is document that SLAP lesion repair was a type 2 or type 4 along with procedure 29806, allow both procedures to reimburse separately, but if 29807 was a SLAP type 1 or 3 continue to maintain the bundling between 29807 and 29806.

ARTHROSCOPY, SURGICAL SHOULDER - Authorization request.

The following CPT code(s) require prior authorization: Code Description

29806 Arthroscopy, shoulder, surgical; capsulorrhaphy

29807 Arthroscopy, shoulder, surgical; repair of SLAP lesion

29819 Arthroscopy, shoulder, surgical; with removal of loose body or foreign body

29822 Arthroscopy, shoulder, surgical; debridement, limited

29823 Arthroscopy, shoulder, surgical; debridement, extensive

29824 Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure)

29825 Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation

29826 Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (i.e., arch) release, when performed (list separately in addition to code for primary procedure)

29827 Arthroscopy, shoulder, surgical; with rotator cuff repair

29828 Arthroscopy, shoulder, surgical; biceps tenodesis 


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